I am attempting to collect all the comments anyone cares to make (good or bad, constructive or de-constructive) regarding my on-going, real-time on-line book, right here. I am hoping that compiling all the comments in one place will help me with the CQI process. Thank you very much for your cooperation.

Thanks for the suggestion. I am going to try it out for a while in the “frontmatter,” which is where authors traditionally stick items which are of (at best) peripheral interest, and which readers can and often do skip over with ease.

Having a bit of frontmatter has the added advantage of making you seem scholarly and such.

Chapter three is a masterpiece.It is beautifully written and as beautifully sad and tragic as it is true.The choir to whom you at least in part preach will likely not bristle with the mention of the Ayn Rand reference,some potential converts may and of course so will the progressives, but they won’t read it anyway. Yet maybe if enough people talk and write about it enough maybe they will have to.After all it was a rather small and very vocal minority who pulled off the destruction of medical ethics.Maybe a small group can reclaim it;if not it will not be your fault.

Thanks, Dr. Gaulte. I will reconsider using the Atlas Shrugged quote. I am a fan of Rand when it comes to diagnosing the problem, and I think this quote is remarkably prescient in predicting what is actually going on today. I am not a fan of Rand’s ultimate solution, however (which centers on godless self-interest).

Not to throw cold water on the effort but I wonder if you are sacrificing clarity for entertainment. You’ve written an awful lot of words to illustrate two very basic economic principles: 1) You can’t consume more than you produce; and 2) bureaucratic allocation of resources will always be much less efficient than market allocation of resources.

All goods, including health care, require someone to expend time and labor to produce them. Because time and labor are available in strictly limited quantities, the amount of all other goods are available in strictly limited quantities.

The choice to expend time and labor to produce one thing means that we are abandoning the opportunity to expend that time and labor to produce something else. Thus, we must prioritize what we choose to produce. We must produce that which we value more before that which we value less.
The quantity produced of a given good matters. The more we produce of a good, the less valuable it becomes. Thus, at some point, producing more of our highest valued good (Good A) becomes less valuable than producing some of our next most valued good (Good B). At that point, we should cease producing Good A in favor of producing Good B. If we continue producing Good A, we create a surplus of that good and a shortage of Good B. Surpluses represent wasted resources. Shortages represent unfilled needs that should have been fulfilled.

In a complex world where production (and consumption) of millions of goods is divided among billions of people, we need a way to ensure that we produce the highest valued goods in the correct quantities with minimum waste of scarce resources. There are really only two ways to do this: 1) markets or 2) planning. Markets involve the spontaneous order established by prices that signal how much of what to produce of any and all goods. Planning is the conscious attempt of designated people to decide how much of what to produce. On both theoretical and empiric grounds, it is well established that markets are much, much more efficient than planning. In fact, planning is so wasteful that everywhere it has been attempted, the results have been catastrophic.

What you call “covert rationing” is the attempt to use planning rather than markets to allocate resources to health care. All of your copious and entertaining writing about “covert rationing” is illustrative of the principle that planning is catastrophically wasteful. As entertaining and illuminating as describing the results of planning (or “covert rationing”) may be, if the underlying principle is not made clear, it may only result in addressing the symptoms rather than the cause, tinkering around the edges rather than reforming the core.

Thanks for your very thoughtful and detailed comment. You may be right. There’s probably some happy medium between my writing style and Tweeting the message (“Market Forces > Central Planning”), but I’m afraid that I’ll never get through this project if I don’t entertain myself in the process, and what you see before you is what it takes to keep me going.

I enjoyed chapter 3. Allow me to play Devil’s Advocate and argue (for a moment) that the “new ethics” are entirely appropriate under the circumstances.

Under the traditional Doctor/Patient relationship, the patient seeks services from the doctor in return for payment. The patient values the services received at least as much as the fee the doctor charges. Therefore the patient is willing to give up payment (resources) up to the perceived value to him of the services received. The doctor’s professional ethical role is to accurately advise the patient as to what benefit the patient may reasonably expect from any given course of treatment in order for the patient to make an estimate of the personal value of each proposed course of treatment.

So far, so good. The doctor is ethically bound to advise the patient for the patient’s benefit as to the costs and best estimate benefits of any proposed course of treatment. This allows the patient to decided whether the expected benefits to him are worth the costs to him.

Now, let’s look at the “modern” situation. Unlike the traditional arrangement where the benefits are reaped and the costs are borne by the patient, the benefits are still reaped by the patient but the costs are borne by others. These others get no benefit whatsoever from the patient’s treatment. (Communitarians might argue this point but, for the sake of this discussion, I suggest we table it.) The patient is now freed of any constraints on what benefits to seek. The patient has become a “benefit monster”, devouring the scarce, valuable resources of all others in the quest for his own health care.

Surely, I might argue, an ethical physician must stand in the breach, protecting the resources of all those innocent bystanders from being consumed by his monstrous patient. To do otherwise would be to stand by while inordinate harm is done, while valuable resources are being generally wasted.

So too in the context of resources “devoted to” health care, if any given patient is allowed to consume those resources wastefully, there will be a shortage of resources to treat other patients’ needs. An “ethical” physician must see to it that resources are available to treat all (potential) patients.

Thus, there is a certain internal logical consistency to the “new ethics”. We can only see the fallacy by stepping outside the assumptions of the “system”.

In truth, this is not a problem of professional ethics at all. Those who seek benefit at the expense of others are thieves and have no claim to ethical treatment. In fact, since, as I described it above, the physician’s traditional ethical responsibility was to help the patient weigh expected benefits against costs, this responsibility is entirely moot where the patient bears no costs.

What about the victims, those who are paying? Surely we owe them an ethical duty? Since you started with Rand, I’ll answer with another of her concepts. They have given “the sanction of the victim”. They agree to pay for strangers because they in turn expect to make others their victims. They expected to be able to feed off others just as they allowed others to feed from themselves. What ethical responsibility would you take up in this war of all against all, in this jungle feeding frenzy?

These new “ethics” are really an attempt to make physicians the referees in a fight among thieves. Worse still, it is an attempt to make physicians take the blame when the system collapses, as it inevitably will. The only way to avoid this is to withhold our own “sanction of the victim”.

I appreciate and largely agree with your analysis of the doctor’s ethical dilemma. To ever have any chance of solving the fiscal problem healthcare currently poses, patients will have to accept a large amount of personal responsibility for the healthcare they “consume.” However, for physicians to change their ethical precepts in the way they have done is counterproductive from every aspect.

I have actually written about this in great detail elsewhere, and have suggested a specific ethical solution to the dilemma, that both preserves medical professionalism and allows for cost control. I will probably discuss it again in Part III of this book, if, God-willing, I can get that far.

But my solution actually looks a lot like the lawyers’ ethical system. They often have to protect the rights of clients who are far more reprehensible in their actions than patients ever could be, and they manage to do it while, at the same time, their clients (usually) wind up having to pay for their sins. This happens because society has set up a set of rules (laws, etc.) under which lawyers have to operate, and which are aimed at achieving some facsimile of “justice” for the greater society. But within that set of rules, the lawyers are able to fight for their clients with everything they have.

No reason the distribution of healthcare resources could not be set up under a similar scheme, so that doctors could fully advocate for their patients under a system of (if you will) rules for distributing public resources. This, in my estimation, could work, as long as patients also retain the prerogative to purchase “extra” healthcare services, if they choose, with their own funds.

I’m in the process of reading the book and have quoted parts of it on my own blog. I have also studied other countries’ health systems and have come to believe that the French have the best compromise. Their other social policies are bankrupting the system, which is a shame because their health plan is the best in Europe and a potential model for us. The basis of it is fee-for-service for most patients who are obliged to pay first and who then receive a reimbursement from the Social Security fund, which is less than the patient payment and based on a fee schedule. The patient and doctor are free to negotiate higher fees but the choice is the patient’s. It is a complex system but far more sensitive to incentives than ours.

I’m continuing to read and greatly appreciate your efforts. Since reading other blogs has become too depressing the past two days, I will speed up my reading of the book.

Overall I agree with your assertion. If you will allow me to summarize your argument as neatly as you summarized Dr. Rich’s earlier, what your argument boils down to is this: “When spending someone else’s money, that someone else gets a say in how it is spent.” One of the largest problems with our current system is that we simultaneously allow that someone else control (via insurance companies, the federal government, etc.) while at the same time saying that people will get everything. Hence covert rationing, which is at its core nothing more than rationing care while denying that any rationing is occurring.

Where I disagree (with your admittedly “Devil’s Advocate” position” is in the role of the physicians. When you have someone simultaneously charged with both providing necessary services to someone while also controlling what services they receive, the resulting conflict of interest is immensely difficult to manage in all but the most idealized situations. The overwhelming majority of people, no matter how intelligent and well-intentioned, simply can’t thread that needle. What’s necessary are not limitless resources to any one patient (which, as you state and all but the delusional would agree with is fiscally impossible), any constraints on what is offered should be constrained by a, transparent, and b, outside sources with c, the option for the patient to pay for anything that someone else’s money doesn’t cover. That prevents patients from crossing the line into thievery while also allowing the physician to be solely dedicated to the welfare of the patient with both knowing that there are simply options that are off the table without personal investment.

But at the end of the day, you work for the person that pays you. Patients no longer pay physicians, insurance companies do, and therefore the doctors work for the insurance companies regardless of their public face. That’s why the concierge physicians are, whether they realize it or not, the most ethical physicians currently practicing: their patients pay the bills and therefore the conflict is resolved.

Those podcasts take a lot longer for me to produce than you might believe. And right now I’m spending every spare minute just trying to write this darned thing, until I either finish or somebody makes me stop. Once I am done I may consider a series of podcasts. In any case I’m glad you enjoy them.

Please consume enough healthcare so as to stay alive until you finish the book.

By the way, I am one of those physician practice managers, whose job it is to keep the doctors solvent while sustaining their belief that their solvency is due to their brilliance. I hope someday to write the book on how the doctors bungled their profession away with no apparent cause except that they could. But that will have to wait till I no longer need a paycheck from doctors.

Tim, if you had sat with me for the years I spent on the CMA’s Commission on Legislation and as an AMA delegate, you would be even more distressed at how the medical profession threw away their future.

Regarding Chapter 4, specifically “Method 3″: In “Method 3″, you are proposing a “middle way”, a compromise between the market and socialized medicine. Let me start by recalling Ayn Rand’s pithy observation that, “In any compromise between food and poison, it is only death that can win. In any compromise between good and evil, it is only evil that can profit.” Perhaps somewhat less contentiously, I would say that adding unworkable features to a working system will never improve that system.

You’ve proposed a “three-tiered” approach: an HSA, followed by government guaranteed “basic” care for all, followed by private insurance.

First, it’s not clear to me what is the purpose of the HSA in “Method 3″. Currently, an HSA is a way to provide the same tax deduction for out of pocket health spending as currently applies to employer-provided health insurance. Since it appears that under “Method 3″ there would be no tax-advantaged employer-provided health insurance, it’s not clear why you would want to (or need to) tax-advantage spending on health care. All this would do would continue the same market distortions that exist under the current system.

Your HSA tier is really just the “deductible” for tier two. Making it tax-advantaged simply amounts to decreasing(!) the deductible and adding to the cost of tier two. Moreover, if (as it appears), tier two kicks in once you’ve spent $2,000 out of pocket, why would anyone accumulate more than $2,000 in their HSA? (I note that you propose that unused HSA funds can roll over into retirement savings, but this just strikes me as a byzantine mixture of unrelated policies.)

Now we come to tier 2, the “Universal Basic Plan”. As you say, “The key to controlling costs is that the dollars which society [that is, the government] will spend on healthcare for individuals must be strictly defined and strictly limited, and cannot be open-ended. Economic principles dictate that public healthcare spending must be limited to pay-as-you-go, and cannot accumulate inter-generational debt.” Let me just add that if my grandmother had wheels, she’d be an Edsel.

Of course, the key to controlling costs is that the government must limit what it spends! The whole f-ing problem is that It Can’t! Not, “doesn’t want to”; not, “has trouble doing so”; not, “could if only we elected the right politicians”; It Cannot. There is a whole school of political science called Public Choice Theory that explains why this is so.

The definition of what is “basic” will expand inexorably because the process of definition is political and political processes are not subject to economic limits. Every dollar allocated to the “UBP” will be spent and more because there are no limits on the consumption of “free” stuff. At the same time, tax payers will balk at paying for the plan, prompting politicians to shift costs to non-voting future tax payers. Politicians will get around your pay-as-you-go rule by “borrowing” to fund other programs, shifting current tax revenues to the “UBP”. In sum, no matter what “limits” you place on the “UBP”, you will have the exact same results you decry under the current system. You can’t design away, elect away, or legislate away the incentives that drive political systems any more than you can repeal the “law” of supply and demand.

And, BTW, the “progressives” will be more than happy to “compromise” with “Method 3″ because they do know where it will end and that will be fine with them.

I will once again assert that the choice we face is not which “plan” to implement. Rather, we must choose between the spontaneous order of the market or the inferior performance of any “plan”.

To any readers who may be following this commentary, Mitch has just given an eloquent argument for Method One.

I have no further answer to this argument than that which I have already related, at rather great length, in Chapter 4. It is for the reader to decide which method is least impractical, and will lead to the least harm.

Enjoyed chapter 5, although I suspect it will make a number of people very uncomfortable. I was wonder if you’d watched any of the Supreme Court hearings this week and if they offered any additional insight into the mindset of the yeas and nays for Obamacare and if you had any thoughts on those you might be posting on. Might be nice to take a break from the book, too.

I sent this to you in an email but realized this might be the more appropriate place for it.

Dr. Rich,

I discovered your covert rationing blog on the blogroll of Avik Roy whom I only discovered recently. I just read Chapter 4 of “Moo” and thought it was great. Well until this…

“Rather, their actual prime objective must be, and can only be, to stifle individual freedom sufficiently to centralize the control of our entire society.”

That is a near textbook example of the Appeal to Motives logical fallacy. The chapter is otherwise brilliant but that whole paragraph will only serve to convince progressives that you are a tool of Fox News. It undermines a credibility that you managed to build quite effectively in the rest of the chapter.

I like the What About Method Four section although progressives will argue that the whole point of reform is to avoid that possibility. And you pretty much tacitly acknowledge that the monopsony power of a single purchaser of health care can hold down costs.

Thank you for taking the time to read some of this book, and especially for your comments.

I have taken your comment under advisement, and have somewhat softened the offending paragraph. I do understand how this paragraph sounds like an Appeal to Motives argument, and I think my edits will make it seem somewhat less stark.

However, I hope you will read Chapter 5, which in fact is dedicated to an analysis of the Progressive’s “motives.” I have taken great pains to avoid merely asserting what their motives are, like some omniscient authority. Instead, I have presented the Progressive Program as a theory, based on observation and testing, and invite the reader to come up with an alternative theory that, in practice, predicts the behavior of Progressives better than mine does. So, in truth this is not a mere Appeals to Motives argument, but in fact is an application of the scientific method in an attempt to discover the aims of the Progressive Program. Since Progressives are obviously not transparent about their aims, they leave us objective observers little other choice.

Frankly, I hope I am very wrong about the Progressive Program, and half my reason for writing this book is to induce somebody to come up with a better theory about it. To be a better theory, however, it will need to explain, better than mine does, the observed behaviors of Progressives.

I have read half of chapter 5 and skimmed the rest. Your book is more ambitious than I realized! In fact, I suspect that it is too ambitious! I think that you are correct that the progressive movement is a movement against individualism.

But most progressives I know are also deeply skeptical of central authority, at least as it pertains to social policy. Progressives are technocrats and tinkerers. They don’t sit around and think, “How can we control the impulses and desires of the unwashed masses?” I think most progressives are motivated by a desire to solve social problems and they inherently believe that some problems can best be solved collectively. And occasionally they are right about that! Most progressives would abhor the horrors inflicted upon the people by communist regimes. Most progressives would be skeptical of any program of societal improvement that would require the suppression of man’s innate instinct to better his lot in life.

There are many problems with progressive thought. Progressives don’t sufficiently appreciate the difficulty of managing complex systems, how incentives lead people to game those systems, how top-down global solutions crowd out private initiative and innovation and create perverse incentives. They don’t appreciate the deep power of self-interest as an organizing principal of society. They don’t sufficiently appreciate trade-offs between alternative sets of solutions or how solutions can be provided through an emergent order. They don’t appreciate the natural instinct within most people to want to help their fellow man and, in fact, propose solutions that suppress those instincts. They certainly don’t appreciate public choice theory.

When I read chapter 5 I don’t think “This is the problem with progressives.” I think, “This is the problem with the political class” whether they are progressive or conservative. Conservatives have their own set of priorities and solutions which it wants to force upon the masses. Conservatives are for liberty except when they aren’t.

Cultures and societies are complex. People are complex. There is no progressive “hive mind”. No conspiracy. Obama isn’t a secret Muslim or communist. Progressives don’t have the goal of suppressing freedoms

So I guess I would raise the same criticism of chapter 5 that I raised before. I think that it undermines the persuasiveness of the other chapters. If, at the margins, you want to be able to influence progressives to think more clearly about why our health care system is broken, I think you will lose them at chapter 5.

If only Rand’s correctness were equal to her eloquence! And of course, Rand’s ethical conundrum is absolutely true if you hold to Rand’s ethical system. Hopefully you can see how, for a non-objectivist thinker, it kind of eliminates the possibility of gray. And I won’t even mention the presence of amygdalin, a cyanide compound, in peach pits!

Okay, my snark alarm is blaring so I will tone it down.

Your deconstruction of Dr. Rich’s system is insightful.

I also appreciate your appeal to public choice. Buchanan is one of my personal heroes so kudos.

The problem is, that your conclusion, like Rand in your opening paragraph, leaves no middle ground and no room for compromise. So by all means, you keep tilting at windmills and cursing the darkness. In the meantime, Dr. Rich and others can continue to try to affect change “at the margins” and propose solutions that might be politically possible. (Sorry snark alarm again).

For the record, I am not an Objectivist. (Why am I hearing echoes in my mind of Richard Nixon avering, “I am not a crook”?) I quoted Rand as I did more as a commentary on “mixed” economics than on ethics. To be more explicit, grafting non-market features to a market will always decrease the efficiency of the market.

“Politically possible” is hardly a recommendation for anything. In fact, what that phrase really means is “business as usual” and “we insiders will keep on fleecing the masses until someday, hopefully long after we’re gone, the whole thing collapses”. Nor do I believe nibbling “at the margins” will do the job.

The problem at hand is due to the attempt to achieve an economic end by a non-market method. It is highly unlikely to be solved by substituting a “different” non-market method. That’s not “tilting at windmills” or ” cursing the darkness”. That’s just the empirically verified fact.

“Health insurance proved so popular that after the war, Congress changed the tax laws to make the insurance premiums paid by employers tax-deductible so as to encourage the practice, and before very long virtually every company provided health insurance to their employees as a matter of course.”

The first such exclusion occurred under an administrative ruling handed down in 1943 which stated that payments made by the employer directly to commercial insurance companies for group medical and hospitalization premiums of employees were not taxable as employee income (Yale Law Journal, 1954, pp. 222-247). While this particular ruling was highly restrictive and limited in its applicability, it was codified and extended in 1954. Under the 1954 Internal Revenue Code (IRC), employer contributions to employee health plans were exempt from employee taxable income. As a result of this tax-advantaged form of compensation, the demand for health insurance further increased throughout the 1950s (Thomasson 2003).

I think the term “progressive” could be replaced with something like “control freak” or “power elite” and be more meaningful. I mean, you’re calling Richard Nixon a “Progressive” which I doubt most people can relate with, regardless of political persuasion.

Our political language is kind of meaningless as it stands now. You say Nixon was a progressive, Obama self-identifies as progressives, and a lot of self-identifying progressives (as well as libertarians) call Obama a neocon. And Romney kind of invented Obamacare!

The inalienable rights Jefferson refers to in the Declaration of Independence are anything but “paranormal” or “supernatural”. In fact, we call them “natural” rights because they are derived from the axiomatic nature of human beings, not from any supernatural source. ( Don’t be confused by the “endowed by their Creator” language. That’s TJ’s conventional reference to how humans got to be the way we are. The rights are derived from the way we are, not from the Creator.)

Jefferson got his ideas about natural rights from John Locke’s Second Treatise on Government. You should read it, especially if you don’t believe me about the “Creator” thing. BTW, since you mention the “Divine Right of Kings”, you might want to look at Locke’s less often read First Treatise on Government which is an elaborate refutation of that concept.

Ayn Rand and Murray Rothbard have written their own derivations of natural rights that are more philosophically rigorous than Locke’s. Those are worth reading, too.

On the whole, I agree with Steve about chapter 5. Don’t get me wrong, I’m always up for the gratuitous bashing of progressives, collectivists, and statists. But it is gratuitous. (Fun but gratuitous.)

I particularly agree with Steve that it is generally not true that progressives have the specific objective to stifle freedom. As Hayek demonstrates in The Road to Serfdom, that is the direction that any attempt to centrally direct economic activity will take, but that doesn’t mean it is the explicit intent of those who seek to direct such activity. This is also not to say, as Hayek also points out, that many people who are attracted to such schemes are not motivated by the desire to bully and rule others, but it is still not the motive of progressivism per se.

I also particularly agree with Steve’s point that the problem of seeking central authority pertains more generally to “the political class” (those I would label “statists”) than simply to progressives.

For my own part, I would add that Communism, Socialism, and Fascism are all forms of collectivism. They are distinguished by how they define the collective and by the way the seek to organize economic activity.

Communism defines the collective as “the workers of the world”. It is a trans-national collective based on “class”. By contrast, Socialism generally defines its collective on the basis of national borders. The collectives of Fascism are also generally national, e.g. Mussolini’s Italy or Franco’s Spain, but the nation may be defined in other terms, such as Hitler’s racial definition.

In terms of economic organization, both Communism and Socialism formally place the ownership of property in the hands of the state. Fascism leaves ownership nominally in private hands, while centralizing the management of all property. In practical terms, the differences are virtually completely unimportant.

You both object to my chapter on Progressivism either because you think it will anger any progressives who might read it, or because you think the premise is wrong, or both.

I agree with you that most American progressives do not believe in Progressivism as I have laid it out. But their Progressive leaders do – as proven by their sustained actions over decades. I have added a section to the chapter to try to differentiate the two kinds of progressives (large and small “p” progressives). Since neither species of progressives will like the message I am attempting to convey, I doubt this will help much to make the chapter more palatable to them – but I hope it will clarify my message a bit.

I do think you are both very mistaken, however, if you believe that Progressivism is just like any other political movement. Yes, power corrupts. And yes, all political leaders, of any school of thought, attempt to consolidate power. But for Progressives, consolidating power (and stifling individual freedom) is not an end in itself, and is not their chief purpose. Rather, consolidating power and stifling freedom is merely a necessary step toward achieving their higher goal. (If people would just behave better, these steps would be entirely unnecessary.)

It is this higher goal that makes them unique – and makes them uniquely dangerous.

In any case, this book-in-progress is meant to be a book about the innate dangers of a Progressive healthcare system – and so a chapter on the Progressive Program, as I see it, is essential. It is one I cannot avoid writing, and one in which I cannot afford to pull punches.

Time will tell whether the two of you are underestimating Progressives, or whether I am simply being paranoid. I sincerely hope you are correct, as there is medication for paranoia.

Read all five chapters today. Excellent book. I have shared this with a few people that I follow on Twitter. One talk show host already re-tweeted it to his 4K+ followers. Looking forward to the next chapter being posted. Keep up the excellent work.

Just found you via SERMO. Have not had time to read all your entries.After reading your commentary on the destruction of the doctor- patient relationship, I wanted to thank you for reminding me why I went to medical school.

Although my practice has been as a diagnostic radiologist,I always considered myself a physician and each study was in fact my “patient”. My role was and is to be a consultant with a professional relationship both to the patient and the ordering physician. I am saddened by what I see as the demise of our professsion with the onslaught of government involvement.

Please continue your observations, perhaps we can several Supreme Court justices will read them .

There is pretty good evidence that CoEnzyme Q10 is harmless and can lead to better blood pressure reductions than 1 to 2 points. Of course the studies are very small. But what the hay – maybe the experts should be looking to forcing all foods to be ‘enriched’ with CoQ10.

This chapter is a good example of how power corrupts and absolute power corrupts absolutely. Checks and balances be damned.

I find no problems with the initial chapter 10. Your insight is incredible and your writing style entertaining. Keep up the good work. As one old fart to another, I appreciate your effort and have posted links to each chapter on my site and hand out links to my patients. You do us all a great service!

Only read Chapter 11. Excellent analysis of the pitfalls of screening tests. And then you lose heart and switch sides.

By the end of the chapter, men and women are no longer harmed by PSA and mammography in greater numbers than they are helped. What happened?

I support the libertarian argument that folks should spend their own money as they see fit, including getting PSAs and mammograms as often as they like. But as long as someone else (i.e., ME) is going to be paying for it, I’d rather follow the guidelines.

And while we’re at it, I hope docs are advising people along the USPSTF guidelines. That’s good medicine.

Dr. Rich,
I am greatly enjoying your book. It is insightful, well written, and tells the story that is not being told. You are currently up to Ch. 11 in part 2. Without “giving away the ending”, do you have an outline of the book? How many parts? How many chapters? etc.
Thanks for all your hard work.

Thanks very much for your kind words. Coming from you I take them as a very great compliment.

I do have an outline, but it’s been a flexible one so far. I expect two or three more chapters in Part 2 (the part that describes the problems with Obamacare), and then I will move on to Part 3, which is supposed to discuss how we might be able to change the path we’re on. Part 3 will be shorter, likely only two or three chapters.

However, we are now getting very close to the time when the SCOTUS will rule on Obamacare, and, I expect, will make a ruling that will require me to have to go back and redo most of what I have done so far. I started this project knowing this might happen, but I am still trying to decide what I should do about it if it does. My message would still be valid (I think) but obviously would have to be entirely reframed. At the moment my intent is to plow ahead and see what happens, since SCOTUS very well may uphold the entire mess, or enough of it to allow the damage of Obamacare to proceed.

Thanks. Looking forward to reading the rest.
I would suggest that if SCOTUS overturns the ACA, you will only need to make minor edits. We are already so far down the path of what you predict will happen, that it would take much more than SCOTUS to reverse course.

Yet another excellent chapter. The “Obesity Epidemic” makes a lot of sense when viewed through your perspective. I often tell my patients that we are moving to a “Soylent Green” scenario. There are many corerelates between today’s world and the movie.

I always took solace in the fact that “Soylent Green” was my paranoia. Unfortunately, your book makes my paranoia look all too real!

Dr. Rich,
Your blog and book are both so valuable because they clearly make the case against socialized medicine and collectivism in an accessible and entertaining way.

This is why I was disappointed to read in your latest post about the alleged Michelle Obama and Oprah Winfrey feud. The first I had heard or read of this incident was in your post, and it sounded so outrageous I did a Google search. There appears to be no independent verification of this event outside of the book you cite; its truth is in dispute.
For this reason the event is little more than gossip and citing it is beneath the dignity of your work. The fact that there are plenty of verifiable incidents of such bigotry only serves to prove your point. Using the Oprah example was completely unnecessary and threatens your credibility.

The content is, in my opinion as a geriatrician and hospice/palliative care physician, chilling and spot-on.
From my experience studying many years ago in Britain in the NHS, it is almost completely accurate … except that their age of stinks-to-be-you is 72, not 75. Perhaps the evidence that “our” Central Authority will use likes 75 as a rounder number – woohoo! We’ll get another few years!

Very well done. Looking forward to going back and starting at the beginning.

I have been going through the chapters, including a couple I had already read. I loved this part:

“When he finally had built up the infrastructure for doing all this, at enormous cost, he went to the health insurers with his first can’t-miss proposition, the very can’t-miss proposition that had enticed his investors to put up the money for WebMd in the first place. Namely, he offered (in exchange for a tiny transaction fee) to process the HMOs’ medical claims for 70 cents per transaction (as compared to the $7.00 per transaction it currently cost them), and furthermore, to complete the transactions in a matter of minutes instead of a matter of months. Much to Clark’s amazement, there were no takers. None. And his dream died on the spot.”

In 1994, after an extensive spine fusion, I retired from surgery practice and, following years of interest in the measurement of medical quality, including years on the California PRO board, I spent part of my retirement funds to spend a year at Dartmouth, where much of Hillarycare was designed. They have had years of experience in trying to measure quality of care, although Jack Wennberg had little experience with surgery. I was particularly interested in ESRD patients and the use of shunts and grafts to provide dialysis access. All ESRD patients are eligible for Medicare and their is a 100% sample of there claims data available for study. I found some interesting results, such as the duration of function of a dialysis access graft is determined, in regression analysis, only by zip code.

Anyway, after finishing and having a large grant application turned down by people who didn’t understand statistics and data analysis, I returned to California and spent about five years learning that large health care organizations were not the slightest interested in measuring quality of care. I eventually gave up. Your analysis is spot on.

I did have the satisfaction of receiving my diploma from Bill Clinton in 1995, and he said “Congratulations, sir !” I was probably the oldest graduate in years if ever.

Dr. Rich,
I started reading your new book 2 nights ago at 2am when I couldn’t sleep. 12 hrs later, I had completed it. Genius.
Sheer genius. Have you done any blogging on Sermo? It is a physician only website and is a fantastic way to communicate with physicians all over the country and would be an avenue to promote your ideas and maybe get some new ones. All political view points are expressed on Sermo.

Extraordinarily persuasive–so much so as to force me to change basic tenets of my beliefs. (I am 70 years old–still look up to my elders.) I do have two issues with Chapter 13: (1) I believe it would be prudent to tag Sarah Palin as an ally, rather than refer to her as inarticulate and illiterate. In fact, you have acknowledged her capacity, even perhaps by virtue of her simplistic or overstated style, to reach the masses with the phrase, “death panels.” Would it not be better to soften the rhetoric and let her strengths support your narrative? (2) I believe reference to yourself as “old fart” undermines the dignity of your style. You are a distinguished senior.

I have one objection to Chapter 9. Standardization of some processes does produce real rewards. I spent a year at Dartmouth learning some methodology in hopes that it could be useful in improving medical quality in some areas. I found, after my time at Dartmouth, that NO ONE was interested in quality in the medical industry. I eventually gave up.

The example, and I’m sure there are others, is the use of respirator protocols in younger post traumatic respiratory failure. The example that particularly impressed me was some years ago and influenced my decision to spent a year and quite a bit of money learning new tricks.

In the 90s, the Intermountain Healthcare system was trying to decide if it was worth the cost to introduce the use of ECMO (http://en.wikipedia.org/wiki/Extracorporeal_membrane_oxygenation) in its trauma cases where there was “post traumatic wet lung” and respiratory failure. They began by trying to standardize respirator protocols, which included fluid maintenance, diuretics, etc. A rules based system was introduced in which orders were generated by the protocol within a EMR system in ICU. The rules could be modified by physicians participating but each modification had to be signed so they could be followed and results attributed to the people involved. After a period of modification, the rules were stable and the results were surprising. The mortality rate of these ARDS case fell by more than 50% and their mortality was below that of the Mass General’s respiratory unit, a sort of gold standard.

In fact, the results modified the indications for ECMO, which was far less necessary.

I agree that herd medicine is to be avoided but some situations, especially in critical care, benefit from standardization.

I had a problem with medical care a few years ago that was so (unecessarily) expensive and I was treated with such disrespect that I started my own blog. Whatever anybody thinks, we patients are no longer autonomous individuals with rights… See all the informed consent laws that are uniformly dispensed with by morphing informed consent into a vague hold harmless agreement solely for the benefit of the medical personnel and their entity. I defy you to TRY to limit treatment. My hospital turned a minor sugery into a $15,000+ dollar ordeal because they failed to recognize that “informed” consent is the doctrine, not “implied” or “inferred” consent. Informed consent and the autonomy of the patient should be the very first thing to look at.

My personal problem was with a patient control drug called Versed. They call it sedation, but it is far from that AND EVERYBODY GETS IT! Not only is it expensive, with a six figure salaried crna administering it, but there are ‘tiers of care’ as well. Then they can claim that because you were compliant after your sedation, that you actually agreed to their program. Most people have amnesia after Versed, so how can you fight this? Even if you don’t have amnesia, they won’t believe you.

There is no reason to have 18 people involved in a 70 minute surgery. If they each make 35-50 dollars an hour, that adds up.

Anyway, I had to have a second surgery to correct the first (expensive) one, and it cost only 1/3. Of course there was no sedation, g/a, no kidney infection, no visits to a counselor for PTSD, none of it. Plus there were on 3 or 4 people involved as opposed to the 18 in the first surgery. Why couldn’t I have the first surgery done as *I* dictated? The medical field itself says that a nerve block without g/a is best for this surgery! But only 1/3 the cost. Get my drift?

I wish that there were $10,000 dollar fines for each breach of informed consent law. If I could have kept only half of the money collected from one single minor surgery I could have paid off my house, gone on a theraputic vaction, bought a new car, and some more besides.

We have tort reform here. That means no lawyer. The hospital was cited for numerous violations and had to rewrite their ‘informed consent’ process, so in a small way I was successful.

What I gave consent for, even though nothing was written down was a nerve block, an opiod pain med along with nausea meds. I also indicated that an additional block or local anesthesia would be fine. I TRIED to limit treatment. I absolutely forbade any drug that would ‘incapacitate me’ as well as g/a.

Instead I got lots of an amnesia and patient control drug called “vitamin v” by my caregivers and described as a simple muscle relaxant. Of course it incapacitated me rendering me helplessly compliant. Too bad for them I didn’t get amnesia. There was a REASON I declined these “treatments”, “therapies”, whatever they want to call it. Experience has shown that I do not respond as expected to drugs.

If anybody has ever had an experience of attempting to deny medical workers plans, then they know what I mean. Versed/Midazolam is nearly ALWAYS used. It’s hard to stop them from using this drug. Almost impossible!

Even IF you decline g/a, it seems that they will give it to you anyway. In my case they claimed that I gave consent for g/a IN THE OR after injections of “vitamin v”! They claimed that by ‘not objecting’ (after I received the ‘sedative’)I gave consent. The anesthesia nurse involved claimed this in WRITING in reponse to my complaint to the nursing board! This is fine with the nursing board. The nursing board feels that regarless of how much Versed I was given, I DIDN’T OBJECT any more and that IS consent.

Sorry if I seem disorganized. I blame it on Versed. Yet another side effect of this wonder drug. I’m not the only one complaining of this problem.

Please compare how one handles problems with the Obamacare and normal insurance. With my insurance I keep sending the bills with explanations until they pay the bill as they always do.
Compared being forced to make a 140 mile drive for the privilege of talking with a worker who knows nothing and cannot give me an answer who sits behind bulletproof glass with an armed guard by her side.
Guess which I prefer.

I also want to add that proving “harm” isn’t as easy as one might think. You have to PROVE that you said no, (hard when medical workers are in charge of documentation) that even if they had explained things properly that you would still have declined treatment. Things like that. How do you prove that? Previous surgeries don’t seem to cut it…

Then there is the whole ‘expert witness’ problem. I found 2 doctors who were willing to testify on my behalf. (pro se) I had one doctor for the egregious violations in informed consent and the problems with the anesthesia drugs used on me against my will. The other was an ortho surgeon (specialist in my ORIF distal radius surgery who has his own devise on the market) who reviewed the horrible results of my surgery for me. He said that with the level of skill demonstrated by my surgeon, that my prognosis would have been poor, even if my surgeon had tried something else like an external fixator. (which was never revealed as an alternative to ORIF)

The problem is that neither one of these expert doctors was an expert WITNESS! They don’t count in my state. I must hire an expert WITNESS to state the obvious. Each would cost between 10,000 and 25,000 plus expenses. No way could I afford that.

So now I understand why I was treated like a stray dog at the facility I went to. The upside is lots more money doing things their way, instead of conforming to what the patient allows and patient rights law. There is no downside.

I’ve enjoyed your book thus far. I, like many others, find it spot-on accurate. I’ve even enticed my wife to read it. She is impressed with the content so far as well. When will the book come out in print?

I hope to put up the last chapter of the book by the end of next week. Then I will be taking a few weeks off to trek into the wilderness where there is no electricity, let alone Internet, and let the thing percolate. Then I will embark on the task of revising this first draft. I hope to have an electronic book published (likely Kindle) some time in September. I may attempt to get a print version going, depending on the response I get to the e-book. But I embarked on this project rather late (in March), and time is of the essence – so I’m doing it this way.

Say a guy who refuses to pay taxes to support firemen and police, yet benefits from their protection of society as a whole?

Or a guy who doesn’t want to pay for the military, but benefits from the protection they afford everyone?

Or a guy who won’t buy health insurance, but goes to the ER, where EMTALA requires that he be treated at public expense?

I suppose we could have a law that everyone would have to get a tattoo of his insurance coverage, and if a guy showed up in an ER without such a tattoo, he’d be left to die on the gurney. That seems to be the method preferred by the Tea party crowds.

As it is, a civilized society usually determines that no one should die for inability to afford medical care, and that Doctors will not be enslaved and forced to work for free, so that everyone should be required to pay for medical care, even if he’s healthy, just as his taxes go to pay for firemen, even if his house isn’t on fire.

Conservatives, who are always championing ‘personal responsibility’, and decrying ‘welfare’ freeloaders would be expected to agree with this idea.

Most people in this country can no longer afford the charges demanded by doctors and hospitals for even minor problems, much less catastrophe.

The idea that everyone should pay for medical care from his own assets could only occur to someone whose circle of friends is limited to those at the country club.

The only alternative to tax-funded universal medical care, is to drive down the income of doctors and medical executives to the levels seen elsewhere in the first world.

Do you have a 3d alternative, other than the blood-thirsty Tea Party ‘let-em-die’ approach?

You are obviously an intelligent and articulate person. So why have you taken the time and effort to construct your well-written comment to attack my ideas, without having read what my ideas are? You are doing what you accuse the Tea Party folks of doing – reflexively reacting based on preconceived (and ill-conceived) notions. Had you read Chapter 4 (which actually elaborates on four alternatives for fixing the healthcare system) you would not have had to ask your accusatory question.

And before you call Conservatives blood-thirsty, please reflect on the fact that, in the 20th century, far more people were killed at the hands of their own governments than were killed in all the century’s wars combined. A healthy skepticism of centralizing power in the government (whether in the name of fairness or anything else) is as evidence-based as it can be.

I agree with all the positive comments. It’s maybe the best introduction to some of these ideas that I’ve come across, or at least lays out a coherent case as to why Obamacare is so inimical to freedom, among its many other problems.

My only minor quibble was blaming Aristotle when it was really Plato and his ideas of elites and collectivism that formed some of the later notions of what became socialism in its many guises. But the more I read…the more I “enjoyed” it in the sense that it helped clarify so much of what the arguments were and what was truly wrong with Obamacare and socialized medicine, and I also believe you managed to thread the needle correctly in terms of trying to explain why medical care IS different enough that it cannot 100% be left to free-market forces (and I say that as someone who is very much otherwise just about as laissez-faire as they come with everything else). I still would argue over some of that, in fact, but you made a cogent argument for why it can’t go to that extreme either.

I’m trying to send it via links to friends, in and out of the medical care field. The sad part is that most people in America, I believe, are brainwashed and can’t think for themselves about these ideas, nor will they spend time to sit and read something like your book. However, I found that doing it a chapter at a time, and digesting that chapter, truly helped ME clarify things, even when there were times I thought I already knew a lot…only to find out you were able to teach me more than I was aware of.

Thanks so much. Oh, the other bad part? I have trouble sleeping at night. I just saw…and I’ve predicted this for some time…Mass doctors will ultimately be coerced to send all test results and all kinds of other ‘metrics’ to state bureaucrats, and will basically have to take on all comers….i.e. all sense of freedom to practice medicine will be 100% irrevocably gone, as they become complete slaves to the state, JUST in order to be able to be GRANTED a license to work.

Ultimately, that will happen everywhere. How else to deal with the many who otherwise want to quit taking Medicaid/Medicare patients if at all possible….they will force all of us to be those slaves and the end of ethical medicine, with doctors trying to do what’s best for the patients and having the freedom to do so, will have come about. Very sad.

In reading the chapter on “What to do” and the potential for “black market medicine,” I was reminded of the character of Doctor Praetorius, not the Frankenstein character, but a physician who is unsuccessful establishing a practice in Germany until he finds work in a small town as a butcher and starts treating people as a sideline. They flock to him, avoiding known physicians, until someone discovers his medical diploma in a drawer. Once his secret is out, that he is really a trained physician, he is driven out of town but he has made enough money so he can start his own clinic.

Part of this story was told in a movie titled, “People Will Talk,” which has a subplot about a single girl getting pregnant (The movie was made in 1950). The story struck me as one alternative to potential pressure on physicians to join the government health plan. Canada did something similar but never banned physicians who did not try to bill the provincial health plans. Many Canadian physicians who I met when they fled to the US in the early 80s, told me how they had thought their patients would stay with them until they discovered the government program was “free.” I think patients are more sophisticated about alternatives now.

RE: Chapter 8 themes: Not only is HHS issuing draconian rules from the Politburo and not only do government agents pose as customers, but customers themselves are now unwittingly recruited as “agents of the dictatorship of the Proletariat.” Allow me to explain. The typical customer of a private practice will be on one or another group or individual plan, the truly self insured are rare. These days, not only do insurers have their HHS imposed rule sets about the care provided by the provider, they also have rule sets applied to outside labs. A “good customer” will have read the rule book from the provider and have all the diag and procedure codes if not memorized, at least on a cheat sheet. So let’s say Dr. Ethical Hypocratus has a series of screens he’d like the customer to undertake prior to an preventive office visit. All well and good, and no doubt driven by the Scientific Method. However, the HHS edicts in most cases have determined that a given matrix of screening and measures is way beyond the Politburo’s lowest common denominator. So the good customer immediately counters the Doctor’s course of investigation. The good customer may even in frustration complain to insurance about the delta between the Doctor’s course the the HHS matrix. Joe “Snitch” Employee at Insurance Inc then reports this back to the HHS Stasi. Dr Hypocratus has become an enemy of the State.

Nice. In fact, of all the messages I’ve received suggesting it’s time for me to die, yours is the most polite and least threatening. So I’ve allowed it to be posted as an example for all the others out there who share your view, and would like to be heard.

Rich, I just found your blog, it’s great. I just heard a story that a woman went to her doctor for a routine check up and he/she recommended a bunch of tests. When the woman asked if the doc if he was worried about something in particular he said no. The reason he suggested them is that there is some provision in Obamacare that says if you don’t get the screening tests, and you get some disease/condition that might have been caught with the test, that you will have to pay more for treatment. I would like to check to see if that is true see what part of ACA that is in.

I know of no such provision in Obamacare. Rather, the new system will likely punish doctors who fail to get their patients to participate in all the provisions detailed by the legislation. The doctor in the apocryphal story you heard is likely employing a technique he/she has thought of for getting patients to cooperate.

Hi
Recently I saw a piece in thenewspaper about a new test for prostate cancer to replace the PSA. This was a gene test that would
assit is determiningnwhether the cancer was aggressive or not.
The test cost over 3000 dollars. I ran the figures and there are millions
of. psa tests done each year and that means
using this test would increase to cost of protate cancer care in the USA by 75 billon dolllars. ( 25 million psa tests each year) medicare refuses to pay for this test. You seem to suggest that by doing this the central authority
is rationing care and that this is wrong. It seems to me that preventing
progress is a necessary and perhaps sufficient conditiom to solving
the health care cost problem.
I certainly do not think that even if everynone. took good care of themselves that the problem would go away. maybe some tests clould
be allowed if you want to pay cash. But the usa can not pay for everything
for everybody all the time.